Hypertonic/Hyperoncotic Saline Attenuates Microcirculatory Disturbances after Traumatic Brain Injury

Härtl, Roger; Medary, Max; Ruge, Maximilian I.; Arfors, K. E.; Ghahremani, Fathali; Ghajar, Jam

doi:10.1097/00005373-199705001-00008

Cited by 100 publications

(31 citation statements)

References 36 publications

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“…19,28 Clinically, HTS and mannitol have each been shown, in several observational and nonrandomized studies, to reduce ICP and improve brain physiology to different extents. In an initial prospective study, Härtl et al showed that 7.5% HTS reduced ICP and increased cerebral perfusion pressure (CPP) in patients with TBI.…”

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confidence: 99%

Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury

Mangat

Chiu²,

Gerber

et al. 2015

JNS

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ObJect Increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) is associated with a higher mortality rate and poor outcome. Mannitol and hypertonic saline (HTS) have both been used to treat high ICP, but it is unclear which one is more effective. Here, the authors compare the effect of mannitol versus HTS on lowering the cumulative and daily ICP burdens after severe TBI. MetHODS The Brain Trauma Foundation TBI-trac New York State database was used for this retrospective study. Patients with severe TBI and intracranial hypertension who received only 1 type of hyperosmotic agent, mannitol or HTS, were included. Patients in the 2 groups were individually matched for Glasgow Coma Scale score (GCS), pupillary reactivity, craniotomy, occurrence of hypotension on Day 1, and the day of ICP monitor insertion. Patients with missing or erroneous data were excluded. Cumulative and daily ICP burdens were used as primary outcome measures. The cumulative ICP burden was defined as the total number of days with an ICP of > 25 mm Hg, expressed as a percentage of the total number of days of ICP monitoring. The daily ICP burden was calculated as the mean daily duration of an ICP of > 25 mm Hg, expressed as the number of hours per day. The numbers of intensive care unit (ICU) days, numbers of days with ICP monitoring, and 2-week mortality rates were also compared between the groups. A 2-sample t-test or chisquare test was used to compare independent samples. The Wilcoxon signed-rank or Cochran-Mantel-Haenszel test was used for comparing matched samples. reSultS A total of 35 patients who received only HTS and 477 who received only mannitol after severe TBI were identified. Eight patients in the HTS group were excluded because of erroneous or missing data, and 2 other patients did not have matches in the mannitol group. The remaining 25 patients were matched 1:1. Twenty-four patients received 3% HTS, and 1 received 23.4% HTS as bolus therapy. All 25 patients in the mannitol group received 20% mannitol. The mean cumulative ICP burden (15.52% [HTS] vs 36.5% [mannitol]; p = 0.003) and the mean (± SD) daily ICP burden (0.3 ± 0.6 hours/day [HTS] vs 1.3 ± 1.3 hours/day [mannitol]; p = 0.001) were significantly lower in the HTS group. The mean (± SD) number of ICU days was significantly lower in the HTS group than in the mannitol group (8.5 ± 2.1 vs 9.8 ± 0.6, respectively; p = 0.004), whereas there was no difference in the numbers of days of ICP monitoring (p = 0.09). There were no significant differences between the cumulative median doses of HTS and mannitol (p = 0.19). The 2-week mortality rate was lower in the HTS group, but the difference was not statistically significant (p = 0.56). cONcluSiONS HTS given as bolus therapy was more effective than mannitol in lowering the cumulative and daily ICP burdens after severe TBI. Patients in the HTS group had significantly lower number of ICU days. The 2-week mortality rates were not statistically different between the 2 groups.http://thejns.org/doi/abs/10.3171/2014....

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Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury

Mangat

Chiu²,

Gerber

et al. 2015

JNS

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“…38 Using intravital microscopy of pial windows, HTS administration after cerebral percussion injury or systemic thermal injury also reduced EC-PMN interactions. 39,40 Liver intravital microscopy has probably yielded the most exciting findings to date about EC-PMN interactions following the differential fluid resuscitation of hemorrhagic shock. Indeed, several studies report decreases in capillary and sinusoidal luminal narrowing and improved flow parameters, 25,[41][42][43] as well as diminished EC-PMN interactions (sinusoids and postsinusoidal venules) in animals resuscitated with hypertonic fluids.…”

Section: Discussionmentioning

confidence: 99%

Hypertonic Saline Resuscitation of Hemorrhagic Shock Diminishes Neutrophil Rolling and Adherence to Endothelium and Reduces In Vivo Vascular Leakage

Pascual

Ferri²,

Seely³

et al. 2002

Annals of Surgery

119

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ObjectiveTo evaluate the in vivo effects of hypertonic saline (HTS) resuscitation on the interactions of endothelial cells (ECs) and polymorphonuclear neutrophils (PMNs) and vascular permeability after hemorrhagic shock. Summary Background DataThe PMN has been implicated in the pathogenesis of EC damage and organ injury following hemorrhagic shock. Compared to Ringer's lactate (RL), HTS resuscitation diminishes PMN and EC adhesion molecule expression and organ sequestration of PMNs. MethodsIn a murine model of hemorrhagic shock (50 mmHg for 45 minutes followed by resuscitation) using intravital microscopy on cremaster muscle, the authors studied PMN-EC interactions and vascular leakage (epifluorescence after 50 mg/kg fluorescent albumin) in three resuscitation groups: HTS (shed blood ϩ 4 cc/kg 7.5% HTS, n ϭ 12), RL (shed blood ϩ RL [2ϫ shed blood volume], n ϭ 12), and sham (no hemorrhage or resuscitation, n ϭ 9). EC ICAM-1 expression was evaluated by immunohistochemistry. Data, presented as mean Ϯ SEM, were evaluated by analysis of variance with Bonferroni correction. ResultsThere were no differences between groups in flow mechanics. Compared to RL, HTS animals (t ϭ 90 minutes) displayed diminished PMN rolling and PMN adhesion to EC at time intervals beyond t ϭ 0. There were no differences between the sham and HTS groups. Vascular leakage was 45% lower in HTS than in RL-resuscitated animals. Cremaster EC ICAM-1 expression was similar in the two groups. ConclusionsUsing HTS instead of RL to resuscitate hemorrhagic shock diminishes vascular permeability in vivo by altering PMN-EC interactions. HTS could serve as a novel means of immunomodulation in hemorrhagic shock victims, potentially reducing PMN-mediated tissue injury.Over 30 years ago, the Vietnam War established the current standard use of isotonic crystalloid fluids (normal saline [NS] and Ringer's lactate [RL]) for the resuscitation of hemorrhagic shock. Subsequent studies have demonstrated that crystalloids represent an effective and inexpensive means to restore intravascular volume and additionally offer a survival advantage over colloids in the resuscitation of traumatic hemorrhagic shock. 1More recently, "small volume resuscitation" 2 with 4 mL of 7.5% NaCl per kilogram of body weight of hypertonic saline (HTS) has been proposed in the treatment of hemorrhagic shock. Whereas isotonic fluid administration requires large volumes, hypertonic resuscitation offers the advantages of ease of transport, speed of administration, and

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“…Furthermore, there is evidence that HS solutions can lead to 1) increased regional perfusion, possibly secondary to dehydration of cerebral endothelial cells and erythrocytes (dehydration of erythrocytes facilitates flow through the capillaries) [12]; 2) increased cardiac output and mean arterial blood pressure (MABP), likely secondary to augmentation of plasma volume and a positive inotropic effect [9••,13••], and the combination of increased MABP and decreased ICP is ideal for increasing cerebral perfusion pressure ([CPP], CPP = MABP -ICP); 3) reduced inflammatory response to brain injury [14]; 4) restoration of normal membrane potentials through normalization of intracellular sodium and chloride concentrations [13]; and 5) improved gas exchange and improved PaO 2 [15] caused by a reduction of extravascular lung volume (Table 1).…”

Section: Mechanism Of Action Of Hypertonic Saline Solutionsmentioning

confidence: 99%

Hypertonic saline for cerebral edema

Georgiadis

Suárez

2003

Curr Neurol Neurosci Rep

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Hypertonic/Hyperoncotic Saline Attenuates Microcirculatory Disturbances after Traumatic Brain Injury

Abstract: Whether the anti-inflammatory effect of HS/DEX plays a role in reducing delayed brain damage (> 6 hours after TBI) or other systemic complications of TBI arises as an important question and should be investigated further.

Cited by 100 publications

References 36 publications

Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury

Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury

Hypertonic Saline Resuscitation of Hemorrhagic Shock Diminishes Neutrophil Rolling and Adherence to Endothelium and Reduces In Vivo Vascular Leakage

Hypertonic saline for cerebral edema

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